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Response to HIV among MSM/TW over time in Peru Since 1990´s: A sanitary control model Periodic medical check-ups in STI clinics STI syndromic management/ free rx HIV testing Condom provision – often used as an incentive Targets: Nr of MSM with at least 4 visits per year. Peer promoters Initially trained to provide information and condoms Over time their role restricted to recruit MSM/TW for periodic medical check-ups; payment based on N recruited Indirectly: empowerment of peer promoters (smaller cities) Over time: increased community participation Empowerment a goal per-se; some legal/HR actions

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What is happening with MSM now? Partial HIV normalization Less fear – not a death sentence, but… HIV remains highly stigmatized – no discussion HIV closet (except among close friends) Certain degree of reduction in condom use – no clear Younger people – still condom norm, but no referents Older generations – ‘condom fatigue’ Serostatus discussions difficult No overt serosorting – mostly seroguessing No other seroadaptive behaviors (except withdrawal) Positive MSM – Disclosure only to steady partners in the capital; viral load only recently factored in by some Boom of internet-based ‘hooking-up’ Also practiced by closeted bisexuals/ non gay-identified MSM

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Key Barriers Stigma, stigma, stigma Le non-dit/le non-parlé (not said, not spoken) Stigma around HIV remains unchanged This is reflected among MSM Even worse among TW because they often do sex work and because their relationships are usually very unequal No services to support disclosure (e.g. couples HTC) No substantial engagement of LGBT organizations in a renovation of HIV discussion Some focused on HIV implementation only (w/GF money) Accusations of the government (genocide) Lack of broader, more rational gay community-level discussion about new needs and opportunities

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Role of New Technologies: TasP HTLC+ (more people diagnosed and accessing treatment earlier) Obvious first step, not yet taken Implies some service expansion and a media campaign Probably well accepted, should be implemented Earlier treatment (with CD4 over 350) Would be acceptable, esp. with serodiscordant couples Barriers Health service expansion needed; new protocol for service availability and delivery Couples are not well defined; legal barriers Cultural barriers?

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Role of New Technologies: PrEP iPrEx study: 55% subjects from Peru If rolled out –need for planning & infrastructure Acceptability Low among stakeholders PLH: competition with treatment Authorities: preconceptions – cost, not necessary, risk compensation LGBT: not engaged! In some cases, opposition with no clear reasons Many people say they could use it Stigma still plays a role: confusion w/treatment, disclosure, mixed messages about utility Why it might be an option now Effective (according to adherence) Condom use is decaying global trend among MSM

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Way Forward? Government Improve quality and consistency of programming Serious effort to address stigma, not only of HIV but also of non- heterosexual sexualities Bring MSM/TW HIV programming up-to-date: testing and access to treatment; address neglected dimensions Society in General (incl. Academia) Assume its share of responsibility: confront stigma; address issues of sexual diversity based on evidence, common sense and human rights; foster discussion LGBT communities and organizations Get out of the HIV closet (in various ways) Get ready to engage in clear discussion vis à vis the new context (sexual practices, sexual realities) Focus on younger people – start acting as a community!